Provider Demographics
NPI:1316469125
Name:CULLENBERG, E. KELTON (DPT)
Entity type:Individual
Prefix:
First Name:E. KELTON
Middle Name:
Last Name:CULLENBERG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 STEVENS LN
Mailing Address - Street 2:
Mailing Address - City:BROWNFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04010-4774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1173 RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1329
Practice Address - Country:US
Practice Address - Phone:207-860-0307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4854225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist